Are serious games ready to capitalise on their ability to cure our ills?
Is the serious-game sector ready to capitalise on videogames’ terrific potential for healing?
We’re in the engineering and computing building at Coventry University, attending the Games For Health UK Conference. It’s an irregularly shaped construction, slanting and jutting in ways that defy old-fashioned architectural thinking. And it’s held together by giant hexagons, themselves irregularly proportioned, their imperfections speaking of the natural world. It feels like an appropriate setting for a discussion of what is increasingly touted as the future of medicine.
As Pamela Kato, professor of serious games at Coventry University and chair of the conference, introduces the day’s proceedings, the audience sits back in ergonomic chairs. The auditorium is packed with academics, developers and practitioners keen to thrash out the landscape of serious games; where they are, and where they can go. After an initial boom in the early 2000s, with a focus on military training and gamification, serious games have dropped out of mainstream view. Health, though, marks one of the key areas in which progress is being made. Crucially, the potential that exists within the field is only just being formulated.
You may remember Re-Mission or Snow World from the mid-noughties. They were, loosely speaking, the breakout hits of the serious-game industry. Mainstream media latched onto them as concrete evidence of videogames’ capacity to effect positive change, these bewildering creations acting as a sharp tonic to the negative press interactive entertainment can attract so dependably.
In Re-Mission, released in 2006, you play as a nanobot, injected into the body to fight off different cancers, infections and the potential side effects of treatment such as chemotherapy. It was designed to effect behavioural change in adolescent cancer patients, to help assist in the delivery of potentially life-saving chemotherapy and antibiotics. Kato – also founding president and CEO of Hopelab, the game’s publisher – oversaw the project as well as conducting the most scientifically rigorous randomised trial on the effects of a game, results of which were published in 2007. “The kids who played our game took more of their chemotherapy and also more of their antibiotics,” Kato tells us. The game shipped 275,000 copies, distributed through medical practices across the US and other parts of the world. It was, at least in serious-game terms, an emphatic success, and pointed to what videogames are capable of in the context of healthcare.
Snow World, developed by Ari Hollander and Howard Rose at the University Of Washington, was actually being used a few years before
Re-Mission, with the first study into its effects being published in 2001. But the story around it has continued to grow. In Snow World, players – generally burn victims – don a VR headset and fight off snowmen in an ice-cold setting. A mix of distraction and psychological persuasion, the winter environment offsets the painful heat sensations the burn victim might hold. And the game is played while painful exercises such as skin stretching are being undertaken, replacing, or used in conjunction with, traditional drug-based pain-relief methods. “VR pain relief delivers,” Rose, now CEO of Deepstream VR, tells us. “And having that precedent is very important.”
But it’s a precedent the serious-game industry doesn’t appear to have capitalised on, at least to the extent that was once forecast. Certainly it’s a view that those within the industry are aware of. “I went to a conference and someone said to me, ‘OK, there’s Snow World and there’s Re-Mission, but there’s nothing else. And your games are really old’,” Kato recalls. “That’s really frustrating in the field.”
The unique nature of these games means that they can’t be compared to traditional releases. Their afterlives, and the research projects that underpin them, set them apart. “We didn’t just make
Re-Mission,” Kato explains. “We said, ‘Does it work? Does it do what we said it would?’” And for Rose, pain-relief projects at Deepstream VR are informed and advised on by Dr Alex Cahana, a pain doctor for 27 years and former head of pain medicine at the University Of Washington. These steps are, of course, necessities. They’re crucial components of
a process whose outcome must be safe and effective, and subject to the same careful scientific evaluation as any other new drug, treatment or practice.
Richard Brady, a specialist colorectal surgeon and the founder of Research Active, echoes not only the need for integrated expertise in the design process but also robust regulation. “There are a lot of products launched from ideas or innovation that don’t always have quality research or data behind them to support the claims that are made,” he tells us. He is, though, keen to emphasise the potential benefits in this shift to digital means of treatment. “It holds great potential in reducing costs of healthcare, in providing consumer-led and patient-centred care, being paperlight and efficient, and being able to collect lots of population-based data that we can use as medics to decide on future advances in medicine.”
The benefits that might be felt are the result of a fundamental shift within healthcare, from a model of treatment within a hospital to one of prevention and therapy through lifestyle. This, Kato tells us, lies at the heart of the push within games for health.
“Our healthcare systems cannot handle the fact that we have done so well by making people live so long,” she explains. “When you live long, you get the gift of having a chronic illness – heart disease, cancer, diabetes, dementia. You go to the hospital, you see a doctor, you have to take your medication every day, you have to change your lifestyle, you have to eat differently. So how do you support that? The excitement around serious games is that we can make those really critically important behaviours fun to engage in.”
Fun: that’s the crucial point. But it’s one that is missed by many serious-game developers. And it’s not only games for health that missed the mark – it’s a problem that has plagued videogames used in a serious way for the past 20 years, educational games bearing the brunt of the criticism. Tim Laning of Grendel Games is all too aware of the problem and the catastrophic effect it can have on a product’s capacity to deliver the type of change it says it can.
“The reasons why some of these serious games are failing is because they’re not games at all,” he says. “They’re not. They’re boring. They nearly don’t
have any actual gameplay. The graphics look horribly outdated. And they might work from an academic point of view, but if the target audience is simply not interested, because it’s not intrinsically motivating, then it’s not going to work.” Righting that wrong is part of Laning and Grendel Games’ current mission. The studio’s tagline, ‘Seriously entertaining’, neatly pokes fun at the term serious games, while also laying out the fundamental route these games need to take in order to become a success. It is, though, a stance that has evolved, along with the studio.
Grendel Games started out as a group of likeminded friends in 1998, based out of Laning’s apartment in Leeuwarden, a small city in the north of the Netherlands. Grendel’s activities ramped up in 2003 when it entered into talks with Microsoft about developing a title for Xbox Live Arcade. That game,
Slave To The Blade, was “a mix of Guild Wars and Mortal Kombat”, Laning says. Although the project would ultimately be cancelled by Microsoft, demands made by the publisher before that point took Grendel down an unexpected, but fruitful, path.
Microsoft wanted motion-captured animation in the game – something of which Grendel had no experience. So the team turned to a local motioncapture company, Motek Entertainment, to assist in delivering it. But as Slave To The Blade teetered back and forth, Grendel was offered an opportunity by Motek’s sister company, Motek Medical, to develop a game for military rehabilitation using infrared motion capture. Motek Medical had already tried and failed to make the concept work on its own. Now it was Grendel’s turn. It was with this project that the company ethos began to be forged.
“Basically, the target audience didn’t like what Motek Medical had built,” Laning tells us. “Academics liked it, physicians liked it, but the target audience – infantry people who had stepped on landmines and had lost their extremities – didn’t like it. The problem became clear and the solution became immediately clear. These were all young guys, guys our age. They were accustomed to playing videogames on their PlayStations and Xboxes that looked like actual videogames. The games themselves were not fun at all. So that’s when we decided to take a look at it.”
That project led to further serious-game work, and gradually the ghost of Slave To The Blade was pushed to the back of the team’s minds. Grendel continued its exploration of rehabilitation in Gryphon
Rider but with a shift in focus away from military personnel towards children, typically those suffering from cerebral palsy or brain damage. Using Microsoft’s Kinect, the player guides their character through a fantasy world using deliberate body movements. The game, ironically, takes advantage of Kinect’s failures and repurposes them for an audience that requires a slower type of game. “Kinect failed because it did a lot of things wrong,” Laning notes. “It tried to work around the fact that it was quite laggy and would have all these other problems. But what Kinect can do very well is perceive slow motions very accurately to control something.”
The game is also entirely customisable, allowing parents and practitioners to quickly and accurately alter settings in order to meet the physical needs of the child playing. “You can press pause and then it will show you all the hurdles that are there and you can increase or decrease the difficulty,” Laning explains. “But you can also set it up so that children can play it who are able to only move their left arm.” There’s often talk of customisation empowering the player, giving them the experience that they want, but Gryphon Rider goes further, giving players the experience they need while also giving them a profound sense of empowerment and agency. This, after all, is a game designed specifically for them, where they might usually be excluded because of the dexterity required to use a typical controller.
Customisation also lies at the heart of Howard Rose and Deepstream VR’s current project, Cool. Like Rose’s previous project, Snow World, it’s being used in chronic-pain clinics and for acute pain relief in hospitals. The experience this time, though, is more open-ended, designed to incorporate a broader range of patients. And part of this drive is the integration of wearable body technology. “The big leap is to bring sensors into this,” Rose explains. “With the rise of wearable computing, it’s not just
FUN: THAT’S THE CRUCIAL POINT. BUT IT’S ONE THAT IS MISSED BY MANY SERIOUS-GAME DEVELOPERS
the same experience every time. It’s creating a world [players] can come and manipulate. The virtual reality knows you and adapts.”
That adaptation is down to the data-collection possibilities of games for health. “VR is something that [practitioners and clinicians] can track. We can get all this data, and then adjust it,” Rose says. “You can modulate it in realtime to say: ‘Well, that’s working? That’s not working? Let’s try this.’ It enables people, I think, to be better at that rehabilitation model.” That flexibility is something Laning is keen to stress, too. “You can literally prescribe playing levels much like you would prescribe medicine for the rehabilitation of your child,” he says.
But games for health aren’t just being used for treatment and rehabilitation. They’re also being used to aid in the training of practitioners, particularly surgeons. Grendel’s biggest commercial success to date, Underground – released on Wii U – is a laparoscopy (more widely known as keyhole surgery) simulator in everything but name. It’s a puzzle game in which you guide two explorers through a fantastical underworld but, crucially, it utilises a novel control mechanic that mimicks the tools used to carry out real-world laparoscopic surgery. Though the game was released in 2015, the control method was prototyped on the original Wii hardware. “The Wii Remote is very accurate but not when you’re flinging it around,” Laning says. Grendel went on to design a custom controller for specialist use: the device costs $250, and it’s been incorporated for laparoscopic training at facilities around the world. Grendel is keen to develop this commitment to surgical training. The week after we speak, Laning and other representatives of the studio will fly out to the US to shore up the details of their biggest project to date, partnering with two of the largest surgical companies in the world. Details at the moment are hazy but Laning tells us, “It’s either going to be mixed reality combined with a dedicated controller, or it might become VR.” And despite the practical application of the technology, it will still fall in line with Grendel’s ethos. “It’s going to be an actual game like the other games we’ve built, with high production values but catering to a completely different public.”
In working with established partners in the medical field, Grendel is creating a distribution model as well as fostering trust with potential users, a crucial factor in the widespread adoption of games for health. “As far as I know, Gryphon Rider is the only game that is being distributed, and reimbursed, by a health insurance company,” Laning says. “And I think that’s important because people need to access it. And if it becomes recognised as a wholesome therapy and a health insurance company stands behind it, that’s a really good signal for parents at home, because it’s really hard for them to tell what’s good from what isn’t.”
That trust is also supported through the embedding of scientific expertise and evaluation into the design process, something Grendel has worked hard to cultivate. “We have two shareholders – one a hospital and the other a health insurance company,” Laning explains. “Which makes sense for us because we get to create a business case based on the statistics, and we get to prove what we’re doing together with the university medical centre by finding the right people worldwide that can help us.”
The benefits are obvious. And that level of scientific evaluation is something Grendel takes incredibly seriously. It’s the reason why Underground took seven years to make and Gryphon Rider took four. “You have to iterate every step of the way and make sure it does what you claim it does,” Laning explains. “What’s basically littering the serious-game industry right now is a minefield of very badly designed serious games that don’t do what they claim to be doing.”
The risks involved in poorly designed games for health are manifold. It’s not just a case of feeling
“YOU CAN PRESCRIBE PLAYING LEVELS LIKE YOU WOULD PRESCRIBE MEDICINE FOR THE REHABILITATION OF YOUR CHILD”
irked that time has been wasted, as might be the case with a traditional game. Safety is key – there’s the potential that harm could be enacted, particularly in the case of a poorly designed rehabilitation game, for example, that pushes the body too far or in the wrong ways. Testing, reflection and iteration must be incorporated at every step of the development process. The downside is that all of these things take time, a point Laning stresses throughout our discussion.
“What you need to understand is that everything in medicine is slow, but it’s also very deliberate,” he says. “I never got that when I went to the first games for health conferences.” But it’s not only because of testing and regulation. “Medicine is a multibilliondollar business. I mean, the game industry is large, but the medical industry is a lot bigger.” Healthcare, then, is a lurching behemoth in comparison to the fleet-footed videogame industry.
There’s no doubt that, although games for health have proven their value in certain circumstances and applications, it will take time for their potential to be realised extensively, and for their widespread integration into health practices. And it will take more companies such as Grendel to push it forward. With its emphasis on fun, rigorous research, and adoption not only by consumers but corporations, plus regional and national governments, the company is paving the way for future developers in the field.
Laning is quick to emphasise the limitations of such a fledgling field, however. “I’m not saying videogames are a solution for everything,” he says. “They’re not. They’re absolutely not.” But given an increasingly ageing population, and the rise in chronic illnesses that has emerged as a consequence, society and its governments are duty bound to explore every possible option. Games are not some form of ultimate cure, but if they’re implemented properly, they can only become increasingly effective parts of healthcare. “We hope to be an example of how you should pull it off,” Laning smiles.
Pamela Kato, professor of serious games at Coventry University
ABOVE Rose hopes to capitalise on the rise of consumer VR for games such as Cool. “Ultimately, we want to help people at home.” RIGHT Weston, a young sufferer of chronic pain, plays Cool using an HTC Vive headset. The pain-relief benefits have been shown to last up to 48 hours after treatment 7
Dr Ted Jones has been using VR to treat pain relief at his clinic, the Pain Consultants of East Tennessee. Here he guides a patient through Deepstream VR’s Cool
Richard Brady, founder of Research Active
Howard Rose, CEO of Deepstream VR
A cancer patient using a Deepstream 3D viewer prototype. Patients don’t note any side effects when playing Deepstream VR’s pain applications
Tim Laning, founder of Grendel Games
Underground is available via Nintendo’s digital store, with 90 per cent of copies sold to hospitals and skills labs. It has a custom controller (right), but it can also be played more traditionally, using the Wii U GamePad
Town is being adapted for territories across the world with food types specific to each region.
RIGHT Children have played an important role in GarfieldGoesTo Town’s development, providing feedback to Grendel through QA reports. The NHS has facilitated this through its connections with schools